Magnolia Health Mississippi Children s Health Insurance Program (CHIP)

Transcription

1 Magnolia Health Mississippi Children s Health Insurance Program (CHIP) Program Overview and Orientation

2 Welcome to Magnolia Health! We thank you for being part of or considering Magnolia s Mississippi Children s Health Insurance Program network of participating providers, hospitals, and other healthcare professionals. Our number one priority is the promotion of healthy lifestyles through preventive healthcare. Magnolia works to accomplish this goal by partnering with the providers who oversee the healthcare of Magnolia members.

3 Agenda CHIP Overview Contracting Eligibility PCP Panel/PCP Assignment Cultural Awareness and Sensitivity Abuse and Neglect Medical Management Value Added Services Claims Submission Appeals and Grievances Web Portal Provider Services Provider Relations Resources

4 Magnolia Health Mississippi Children s Health Insurance Program The Children s Health Insurance Program ( CHIP ) is designed to provide health care insurance for children in families without health insurance or with inadequate health insurance. CHIP covers children from birth to age 19. CHIP is administered by the Mississippi Division of Medicaid ( hereinafter, DOM ). Eligibility is continuous for one year. There are no premiums or deductibles, although there may be a small co-payment for some services for higher-income families on CHIP. 4

5 WHAT IS CHIP & HOW IT WAS CREATED? Section 4901 of the Balanced Budget Act of 1997 ( BBA ) amended the Social Security Act (the Act) by adding a new title XXI, the State Children s Health Insurance Program ( SCHIP ). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children. On February 4, 2009, President Obama signed the Children s Health Insurance Program Reauthorization Act of 2009 ( CHIPRA ). This legislation provided states with significant new funding, new programmatic options, and a range of new incentives for covering children through Medicaid and CHIP. One of the clear goals of CHIPRA is to support states in developing efficient and effective strategies to identify, enroll, and retain health coverage for uninsured children who are eligible for Medicaid or CHIP, but who are not enrolled. 5

6 PROGRAM OVERVIEW (cont.) The Patient Protection and Affordable Care Act (March 23, 2010), as amended by the Health Care and Education Reconciliation Act of 2010 (March 30, 2010) are collectively known as the Affordable Care Act ( ACA ). The ACA expands access to health coverage through improvements in Medicaid and CHIP, and the establishment of the new Affordable Insurance Exchanges. 6

7 CHIP Contracting Magnolia Health has a contractual agreement with Mississippi Physicians Care Network (MPCN) to utilize their network of practitioners and facilities statewide for the Magnolia Health Mississippi Children s Health Insurance Program (MS CHIP). Practitioners & Facilities that have a current agreement with MPCN will be considered participating for the Magnolia MS CHIP network. Practitioners that currently DO NOT have a contract with MPCN and wish to participate with Magnolia Health MS CHIP will be required to participate and contract with MPCN who will manage the Magnolia CHIP network to include contracting and credentialing of the providers that wish to participate. For additional information about MPCN, please contact to speak to a representative. EXCEPTION: Federally Qualified Health Clinics (FQHC) and Rural Health Centers (RHC) that are currently contracted with Magnolia Health are automatically amended to participate in the Magnolia MS CHIP product. FQHC s or RHC s that are NOT contracted with Magnolia Health can contact a representative in our Network Development and Contracting Department at No Out-Of-Network benefits will be available for the Magnolia Health MS CHIP

8 CHIP ELIGIBILITY Eligibility for CHIP will be determined by the Division of Medicaid according to rules approved by the Division of Medicaid. Application will be made on the same form, which is used to apply for Medicaid. Eligible Child: An Eligible Child is defined as a Low-income Child who meets the following criteria: Is a Mississippi resident with intent to stay; Does not have creditable health coverage at the time of application; Is not eligible for Medicaid; Is not an inmate of a public institution or a patient in an institution for mental diseases. 8

9 CATEGORIES OF ELIGIBILITY CHIP From Age To Age Above (%FPL) Up to & Including (% FPL)

10 CATEGORIES OF ELIGIBILITY MississippiCAN Category of Eligibility Age Category of Eligibility Age Pregnant Women 8-65 (below 185% FPL) Newborns (below % FPL) Children (TANF) 1-19 Children (<age6) 1-5 (<133% FPL) Children 6-19 (<age19)(<100% FPL) Quasi-CHIP (100% % FPL) (previously qualified for CHIP) Children (Beginning 1-19 SFY 2015) SSI 0-65 Working Disabled Disabled Child 0-19 Living at Home Breast and Cervical Cancer Foster Care and 0-19 Foster Care Adoption Assistance TANF Adults Native Americans 0-65

11 Quasi-CHIP / MississippiCAN As of January 1, 2014, States determine income eligibility for children using the modified adjusted gross income (MAGI) methodology. Section 2101(f) of the ACA provides that states maintain coverage under a separate CHIP for children who lose Medicaid eligibility. Magnolia s MississippiCAN will accommodate children who are now in this Quasi-CHIP category, as a result of the elimination of the application of income disregards under Section 1902(e)(14) of the Social Security Act. The Centers for Medicare and Medicaid Services ( CMS ) amended 42 C.F.R , with the addition of paragraph (d), to include these children in the definition of a targeted low-income child.

12 Quasi-CHIP / MississippiCAN 2101(f) protection applies only to children who are enrolled in Medicaid as of December 31, 2013, and who, at their first renewal where MAGI methodologies are applied, are determined ineligible for Medicaid as a result of the elimination of income disregards and are not otherwise eligible for existing, separate CHIP. States must provide coverage through a separate CHIP until the child s first scheduled annual review (12 months), with the following exceptions: The child reaches age 19; The child moves out of state; Voluntary disenrollment is requested; or The child dies.

13 PROTECTING OUR NEW ENROLLEES Under the ACA, states must apply the new MAGI Methodology. Magnolia Health is committed to protecting our new enrollees from any disruptions as they transition from CHIP to MississippiCAN or vice versa. This process is known as churn, which is caused by a change in eligibility status due to fluctuations in income, loss of job, or changes in family circumstances. Please pay close attention to the preceding slides that discuss the categories of eligibility (COE) for both CHIP and MississippiCAN. Magnolia Health has in place processes that protect our new enrollees and members by ensuring a smooth transition in care and ensuring that our new enrollees and members are empowered in their continuity of care process.

14 Magnolia CHIP ID Cards

15 BENEFITS FOR MAGNOLIA HEALTH MISSISSIPPI CHIP Inpatient Services Medical Services Surgical Services Clinic Services Prescription drugs Over the counter medications Laboratory and radiological Services Prenatal care and pre-pregnancy family planning services and supplies Mental Health Services Durable medical equipment and other medically-related or remedial devices Disposable medical supplies 15

16 MORE BENEFITS... Home and community-based health care Services Nursing care Services Abortion Dental Services Other Dental Services Substance Abuse treatment Services Case Management Services Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders Hospice Care Anesthesia Transplants Manipulative Therapy Optometric Services Medical Transportation Bariatric surgery Preventive Services for Women 16

17 MississippiCAN vs CHIP MississippiCAN Unlimited PCP & Specialty Visits No Copays! 6 Prescriptions Every Month No Copays! 1 Eye Exam & 1 Pair of Eyeglasses Every Year for Adults. CentAccount Rewards Card for Healthy Behaviors (including $20 for Annual Mammogram, $50 for Completion of all Diabetic Screenings, $25 for PCP Wellness visit in 90 days, etc.) Rewards may be used to assist with Health Related Items and Utility Bills. Free temporary cell phone for qualified high risk members needing frequent contact with their providers and case managers. There is no charge for the phone or service. 24/7/365 Nurse Advice Line staff with Registered Nurses. Local Call Center CHIP There is no cost sharing for American Indian/Alaska Native Children. No cost sharing is applied to preventative services, including immunizations, well child care, routine preventative and diagnostic dental services, routine dental fillings, routine eye examinations, eyeglasses, or hearing aids. No premiums, deductibles, or co-insurance. Minimal Copay only if your Family Poverty Level (FPL) exceeds 151%. 1 Eye Exam & 1 Pair of Eyeglasses Every Year for Children. CentAccount Rewards Card that can be used at participating stores to pay for personal and medical items. Free health information phone line staffed with registered nurses who are on call 24 hours a day, 365 days per year. Free cell phones for high risked members to assist with care and disease management. Start Smart For Your Baby Program for young girls and new mothers.

18 COST SHARING No deductible amount is required under this Program. No co-insurance is required under this Program. Co payments: No co-payments may be charged for immunizations, well baby and well child care, preventive dental services, routine dental fillings, vision screening, hearing screening, eyeglasses, and hearing aids. No co-payments are to be charged to Enrolled Children in families with an annual income up through 150 percent of the Federal Poverty Level ( FPL ). No co-payments are to be charged to Enrolled Children of American Indian/Alaskan Native descent. 18

19 COST SHARING Requirement Per Doctor Visit <150% FPL None 151%-175% FPL $ %-209% FPL $5.00 Per ER Visit None $15.00 $15.00 Out-of-Pocket Maximum NA $800 $950

20 Dental Dental Services for Magnolia Health Mississippi CHIP will be administered by our contracted vendor Dental Health and Wellness. Please call for additional questions concerning dental benefits and/or questions. Dental benefits are limited to $2000 per calendar year Benefits will include: Preventative and Diagnostic Restorative Endodontic Periodontic Surgical dental services (some oral surgery services may be considered medical in nature and not apply to the $2000 dental maximum) No benefits for orthodontics, dentures, occlusion reconstruction, or inlays unless services were due to an accidental injury or in cases of severe malocclusions, which would require pre-authorization Diagnosis and treatment for temporomandibular joint (TMJ) disorder or syndrome and craniomandibular disorder is subject to a lifetime maximum of $5000 per member.

21 Verify Eligibility It is highly recommended to verify member eligibility on the date services are rendered due to changes that occur throughout the month, using one of the following methods: Log on to the Medicaid Envision website at: (pending) Log on to the secure provider portal at Call our automated member eligibility interactive voice response (IVR) system at Call Magnolia Provider Services at (MEMBER ID CARDS ARE NOT A GUARANTEE OF ELIGIBILITY AND/OR PAYMENT)

22 PCP Panel/PCP Assignment PCP Panel: PCPs can locate and download their panel list by accessing our secure web portal at Log on using your username and password and select Patients at the top of the screen. Providers have the option to download their panel list to an Excel spreadsheet. Panel list includes information regarding eligibility, care gaps, and case management/disease management alerts. Providers are encouraged to use this tool, as it is the most up-to-date method for tracking their member panel. Members have the option to select a PCP. If no selection is made within 30 days of enrollment, the member is auto-assigned to a PCP. Magnolia Health will use an Auto-Assignment Algorithm to assign an initial PCP. The Auto-Assignment Algorithm assigns members to a PCP according to the following criteria: Member history with a PCP: The algorithm will first look for a previous relationship with a network PCP. Family history with a PCP: If the member has no previous relationship with a PCP, the algorithm will look for a PCP to which someone in the member s family, such as a sibling, is or has been assigned. Appropriate PCP type: The algorithm will use age, gender, and other criteria to ensure appropriate match, such as children assigned to pediatricians and pregnant women assigned to OB/GYNs. Geographic proximity of PCP to member residence: Auto-assignment logic will ensure members travel no more than 30 miles in rural regions and 15 miles in urban regions. 22

23 Cultural Awareness and Sensitivity Providers must ensure that: Members understand that they have access to medical interpreters, signers, and TDD/TTY services to facilitate communication without cost to them. Medical care is provided with consideration of the member s race/ethnicity and language and its impact/influence of the member s health or illness.

24 Waste, Abuse, and Fraud (WAF) System Magnolia takes the detection, investigation, and prosecution of fraud and abuse very seriously. Our WAF program complies with MS and Federal laws, in conjunction with Centene, we successfully operate a WAF unit. Centene s Special Investigation Unit (SIU) performs back end audits which may result in taking appropriate action against those who commit waste, abuse, and/or fraud either individually or as a practice. These actions may include but are not limited to: Remedial education and/or training around eliminating the egregious action More stringent utilization review Recoupment of previously paid monies Termination of provider agreement or other contractual arrangement Civil and/or criminal prosecution Any other remedies available Some of the most common WAF submissions seen are: Unbundling of codes Up-coding Add-on codes without primary CPT Use of exclusion codes Excessive use of units Diagnosis and/or procedure code not consistent with the member s age and/or gender Misuse of benefits Claims for services not rendered If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential hotline at

25 Medical Management Hours of operation are Monday through Friday from 8:00 a.m. to 5:00 p.m., CST (excluding holidays) Services include the areas of utilization management, case management, disease management, pharmacy management, and quality review Clinical services are overseen by the Magnolia Medical Director (Medical Director). The Vice President of Medical Management is responsible for direct supervision and operation of the department. To reach the Medical Director or Vice President of Medical Management, please contact: Magnolia Health Plan Utilization Management Fax

26 Prior Authorization vs. Referral Prior Authorization Prior Authorization is a request to the Magnolia UM (Utilization Management) department for approval of services on the prior authorization list before the service is rendered Referrals PCP coordinates healthcare services and are encouraged to refer a member when medically necessary care is needed that is beyond the scope of the PCP Paper referrals are not required PCP must obtain prior authorization from Magnolia for referral to certain specialty providers as noted on the prior authorization list All out-of-network services require prior authorization as further described herein. Please refer to in network specialists 26

27 Prior Authorization Process ALL OUT OF NETWORK SERVICES REQUIRE AN AUTHORIZATION Services that require authorizations can be found on Magnolia s website. It is highly recommended to initiate the Authorization process at least 5 calendar days in advance for non-emergent services The PCP should contact the UM department via telephone, fax, or through our website with the appropriate clinical information to request an authorization Escalated requests can be requested from the Medical Management department as needed (Emergency room and urgent care services never require prior authorization)

28 Prior Authorizations A prior authorization form must be submitted prior to services being rendered for services that require authorization. Providers should ensure to complete the applicable form for Inpatient and Outpatient services. It is highly recommended that providers utilize Magnolia s Smart Sheet to assist with Prior Authorization requests. Prior authorization list is located at: Form can be located on our website at the following addresses: Requests can be faxed to: (CHIP) Requests can be ed securely to: MagnoliaAuths@Centene.com

29 Care Management Magnolia s Care Management Program uses a multidisciplinary team approach to provide individualized process for assessment, goal planning and coordination of services. The Care Management Program is available to all members, emphasizing prevention and continuity of care. Magnolia s Care Management team provides assistance with complex medical conditions, health coaching for chronic conditions, transportation assistance to appointments, interpreter services, location of community resources, and encouragement of self-management through disease education. The Care Management team will incorporate the provider s plan for the member into our Care Plan, so we can focus on the same problems and same care interventions. 29

30 HEDIS/WELL CHILD CARE HEDIS (Healthcare Effectiveness Data and Information Set): One of the most widely-used set of health care performance measures in the United States Includes 81 measures, focusing on prevention, screening, and maintenance of chronic illnesses Information is collected via claims or through medical record review. HEDIS scores are used to compare health plans. They show us how well we educate our membership and provide access to quality care. Members and providers can see our yearly HEDIS scores on our website Providers can get information on how well they (or their practice) are managing their member panels in comparison to their peers. WELL CHILD CARE VISITS: Comprehensive and Preventive Child Health Program for individuals under the age of 19 years WELL CHILD CARE services must be documented in the member s medical record. Please bill vaccines with specific antigen codes to Magnolia Health Mississippi CHIP. For the CHIP Program a provider cannot participate in the Vaccines For Children (VFC) program and bill for CHIP children. This will ensure we receive HEDIS information and the child is up-to-date on immunizations. It will also help improve Magnolia Health HEDIS rates. (Please note, payment will be made for the accompanying administration code only.) For information on proper documentation of WELL CHILD CARE services, please contact Sai Kota at or skota@centene.com 30

31 Value Added Services Connections MemberConnections is a program that promotes preventive health and connects you to quality healthcare and community social services. MemberConnections Representatives are specially trained staff that provide support to Magnolia members. ConnectionsPLUS is part of the MemberConnections program that provides free cell phones to certain members who do not have safe, reliable access to a telephone. This program allows our members to have 24-hour instant access to providers, case managers, Magnolia staff, telehealth services, and 911. To learn more about the program, please contact Member Services at or log onto our website at Nursewise NurseWise is our 24-hour, seven (7) days per week nurse line for members. NurseWise s registered nurses provide basic health education, nurse triage, and answer questions about urgent or emergency access. Our staff often answers basic health questions, but is also available to triage more complex health issues using nationally-recognized protocols. Members with chronic problems, like asthma or diabetes, are referred to case management for education and encouragement to improve their health. We provide this service to support your practice and offer our members access to a registered nurse on a daily basis. If you have any additional questions, please call Provider Services or NurseWise at

32 Value Added Services CentAccount Rewards program for members Earn rewards by completing healthy behaviors Can be used to purchase health related items and help pay utilities Rewards are provided after the claim is filed and paid Members can check their card balance by calling Form more information regarding the program, please visit

33 Pharmacy USScript Pharmacy Benefit Manager Covers prescription drugs and certain over-the-counter (OTC) Some medications require a PA Preferred Drug List (PDL) is available at in the Practice Improvement Resource Center Contact USScript Prior Authorization Fax Prior Authorization Phone Clinical Hours Monday - Friday 10:00 a.m.-8:00 p.m. (EST) Help Desk Line Mailing Address US Script, 2425 W Shaw Ave, Fresno, CA

34 ED Policy Magnolia utilizes a network of hospitals to provide services to Magnolia members. Hospitals are requested to: Notify the PCP immediately or no later than the close of the next business day after the member s appearance in the emergency department (ED) Obtain authorizations for selected outpatient services as listed on the current prior authorization list, except for emergency care and post-stabilization services Notify Magnolia s Medical Management department by sending an electronic file daily of all emergency room admissions for the previous business day. The electronic file should include the member s name, Magnolia member ID, presenting symptoms/diagnosis, date of service (DOS), and member s phone number Notify Magnolia s Medical Management department of all newborn deliveries on the same day as the delivery Magnolia hospitals should refer to their contract for complete information regarding the hospitals obligations and reimbursement 34

35 Clinical Protocols Magnolia affirms that utilization management decision making is based only on appropriateness of care and service and the existence of coverage. Magnolia does not specifically reward practitioners or other individuals for issuing denials of service or care. Consistent with 42 CFR 438.6(h) and , delegated providers must ensure that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. Magnolia has adopted utilization review criteria developed by McKesson InterQual products to determine medical necessity for healthcare services. InterQual appropriateness criteria are developed by specialists representing a national panel from community-based and academic practice. InterQual criteria cover medical and surgical admissions, outpatient procedures, referrals to specialists, and ancillary services. Criteria are established and periodically evaluated and updated with appropriate involvement from providers. InterQual is utilized as a screening guide and is not intended to be a substitute for practitioner judgment. Magnolia s Medical Director reviews all potential medical necessity denials and will make a decision in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm in the screening criteria. Please visit the Practice Improvement Resource Center (PIRC) at for Clinical Practice Guideline and Preventative Guidelines 35

36 Claims Filing ALL Claims must be filed within 180 days from the Date of Service (DOS) All requests for correction, reconsideration or adjustment must be received within 90 days from the date of notification or denial Providers should include a copy of the Explanation of Payment (EOP) when other insurance is involved or provide information when billing electronically Option to file electronically through clearinghouse Option to file directly through Magnolia website Claims must be completed in accordance with Division of Medicaid billing guidelines All member and provider information must be complete and accurate Option to file on paper claim 1 ST time paper claims, mailed to: Magnolia Health Plan Attn: CLAIMS DEPARTMENT P.O. Box 5040 Farmington, MO Paper claims are to be filed on approved CMS 1500 (NO HANDWRITTEN OR BLACK AND WHITE COPIES) To assist our mail center in improving the speed and accuracy to complete scanning please take the following steps when filing paper claims: Remove all staples from pages Do not fold the forms Make sure claim information is dark and legible Please use a 12pt font or larger Please use the CMS 1500 printed in red (Approved OMB Form CMS-1500 (02-12) Red and White approved claim forms are required when filing paper claims as our Optical Character Recognition ORC scanner system will put the information directly into our system. This speeds up the process and eliminates potential sources for errors and helps get your claims processed faster FILE ONLINE AT

37 Electronic Clearinghouse If a provider uses EDI software but is not setup with a clearinghouse, they must bill MHP via paper claims or through our website until the provider has established a relationship with a clearinghouse listed on our website Provider Office EDI Claims Software EDI Claims Clearinghouse Magnolia Processing Payment to Provider Office Centene EDI Help desk: , ext or Acceptance of COB 24/7 Submission 24/7 Status For a complete listing of approved EDI clearinghouse partners, please refer to MagnoliaHealthPlan.com

38 Corrected Claim, Reconsideration, Claim Dispute All Requests for corrected claims, reconsiderations or claim disputes must be received within 90 days of the original Plan notification (ie. EOP). Original Plan determination will be upheld for requests received outside of the 90 day timeframe, unless justification is provided to the Plan to consider Corrected Claims Submit via Secure Web Portal Submit via an EDI Clearinghouse Submit via paper claim: Magnolia Health PO BOX 5040 Farmington, MO (Include original EOP) Reconsideration Written communication (i.e. letter) outlining disagreement of claim determination Indicate Reconsideration of (original claim number) Submit reconsider to: Magnolia Health Attn: Reconsideration PO BOX 5040 Farmington, MO Claim Dispute ONLY used when disputing determination of Reconsideration request Must complete Claim Dispute form located on MagnoliaHealthPlan.com Include original request for reconsideration letter and the Plan response Send Claim Dispute form and supporting documentation to: Magnolia Health Attn: Claim Dispute PO BOX 5040 Farmington, MO Must be submitted within 90 days of adjudication

39 Complaints/Grievances A Complaint/Grievance is a verbal or written expression by a provider which indicates dissatisfaction or dispute with Magnolia Health s policies, procedures, or any aspect of Magnolia Health s functions. Magnolia logs and tracks all Complaints/Grievances. A provider has thirty (30) calendar days from the date of the incident, such as the date of the EOP, to file a Complaint/Grievance. Magnolia shall provide a written determination to the provider within thirty (30) calendar days upon receipt of complete documentation. The reconsideration and/or claim dispute process must be followed first for a Complaint/Grievance related to a claim determination. Full details of the claim reconsideration, claim dispute, complaints/grievances and appeals processes can be found in our Provider Manual at: MagnoliaHealthPlan.com

40 Taxonomy Code / CLIA Rendering Taxonomy Code: Claims must be submitted with the rendering provider s taxonomy code in the shaded portion of Box 24J and Taxonomy qualifier ZZ in the shaded portion of Box 24I if the rendering NPI and billing NPI are different If the rendering NPI and billing NPI are the same, the applicable taxonomy utilizing the ZZ Qualifier is filed in Box 33b The claim will reject if the taxonomy code is not present CMS 1500 form Box 33b, group Taxonomy utilizing the ZZ qualifier in Box 33b if the rendering NPI and billing NPI differ CMS 1450 form Box 81 CC, Taxonomy code with B3 Qualifier This is necessary in order to accurately adjudicate the claim The following website can be utilized to verify a taxonomy code: CLIA Number: If the claim contains CLIA certified or CLIA waived services, the CLIA number must be entered in Box 23 of a paper claim form or in the appropriate loop for EDI claims Claims will be rejected if the CLIA number is not on the claim

41 Common Billing Errors Code Combinations not appropriate Timely Filing Diagnosis code not appropriate or missing digits Unbundling Illegible paper claims (handwritten claims) Duplicate Claims Common Billing Errors TIN or NPI missing or mismatch For a complete list of common billing errors refer to the Magnolia Provider Manual

42 Magnolia Health Website

43 Magnolia Health Website Submit: Claims Provider Complaints Demographic Updates Verify: Eligibility Claim Status View: Provider Directory Important Notifications Provider Training Schedule Practice Improvement Resource Center (PIRC) Claim Editing Software Provider Newsletter Member Roster for PCPs Member Care Gaps CHIP section will be added to website 01/01/15

44 Practice Improvement Resource Center (PIRC) The Practice Improvement Resource Center (PIRC) offers information to assist providers be more efficient and make resources available 24 hours a day: Forms and Guides for the following: Contracting/Credentialing Prior Authorizations Claims Provider Manual Magnolia Vendors HEDIS Reference Guides Pharmacy PDL s and Guides Provider Training Clinical Practice Guidelines Updates.. and more!! CHIP section will be added to website 01/01/15

45 Magnolia Secure Web Portal REGISTER FOR THE MAGNOLIA SECURE WEB PORTAL BENEFITS INCLUDE: Claim submission/corrections and status Prior Authorizations submission and status Patient Panel listing Care gap identification Member eligibility verification Updates.. and more!! CHIP Secure Portal will mirror MSCAN

46 MRI * CT SCAN * PET SCAN Authorization An authorization is required for MRI-CT SCAN-PET SCANS National Imaging Associates (NIA) has been selected by MHP to administer the program The servicing provider (PCP or Specialist) will be responsible for obtaining authorization for the procedures Servicing providers may request authorization and check status of an authorization by: Accessing Utilizing the toll free number Inpatient and ER procedures will not require authorization All claims should be submitted to MHP through the normal processes, electronic submission or paper claim submission Providers can contact Charmaine Gaymon, Provider Relations Manager at or via at CSGaymon@magellanhealth.com

47 Behavioral Health Cenpatico is the behavioral health vendor for Magnolia Health. Cenpatico is a whollyowned subsidiary of Centene Corporation, which has been nationally recognized for innovative service programs and contemporary approach in handling the needs of the diverse populations in the markets proudly served. If you are interested in partnering with Cenpatico or would like more information, please call or visit Prior Authorizations for Behavioral Health can be faxed to Claim submissions for Behavioral Health can be mailed to: Cenpatico PO BOX 7600 Farmington, MO CONTACTS: Network Manager: Angela Stewart anstewart@cenpatico.com (601) Provider Relations Specialist: Nakisha Montgomery nmontgomery@cenpatico.com (601)

48 PaySpan Health Magnolia has partnered with PaySpan Health to offer expanded claim payment services Electronic Claim Payments (EFT) Online remittance advices (ERA s/eops) HIPAA 835 electronic remittance files for download directly to HIPAA-compliant Practice Management or Patient Accounting System Register at: For further information contact , or

49 Provider Services (Call Center) Provider Services Call Center: Provides phone support First line of communication Answer questions regarding eligibility, authorizations, claims, payment inquiries Available Monday through Friday, 8am to 5pm CST

50 Provider Relations Provider Contract clarification Schedule inservices/training for new and existing staff Web Demonstration Provider Education Education and information on electronic solutions to authorizations, claims, etc. Initiate credentialing of new providers Policy and Procedure clarification

51 Provider Relation Contacts NORTH TERRITORY - ASHLEY ARMSTRONG AARMSTRONG@CENTENE.COM CENTRAL TERRITORY - SENITA MILLER SEMILLER@CENTENE.COM SOUTH TERRITORY - TINA PRICE TLAWRENCE@CENTENE.COM DIRECTOR, PROVIDER RELATIONS - WALTER PAWLAK WPAWLAK@CENTENE.COM

52 RESOURCES: CMS.gov ( HHS.gov ( Healthcare.gov ( InsureKidsNow.gov ( Medicare.gov ( 52

53 Thank you!